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RESEARCH ARTICLE
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Citation: Romsics L, Segatto A, Boa K, Becsei R,
Rózsa N, Szántó I, et al. (2020) Dentofacial mini-
and microesthetics as perceived by dental
students: A cross-sectional multi-site study. PLoS
ONE 15(3): e0230182. https://doi.org/10.1371/
journal.pone.0230182
Editor: Wen-Jun Tu, Chinese Academy of Medical
Sciences and Peking Union Medical College,
CHINA
Received: December 12, 2019
Accepted: February 23, 2020
Published: March 12, 2020
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https://doi.org/10.1371/journal.pone.0230182
Copyright: © 2020 Romsics et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The raw dataset is
hosted at FigShare (DOI: 10.6084/m9.figshare.
PLOS ONE | https://doi.org/10.1371/journal.pone.0230182 March 12, 2020
Dentofacial mini- and microesthetics as
perceived by dental students: A cross-
sectional multi-site study
Lı́via Romsics1, Angyalka Segatto2, Kristóf Boa1, Roland Becsei1, Noémi Rózsa3,
Ildikó Szántó4, Judit Nemes5, Emil Segatto ID1*
1 Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Szeged, Szeged, Hungary,
2 Segatto Dent’art Studio, Budapest, Hungary, 3 Department of Paediatric Dentistry and Orthodontics,
Faculty of Dentistry, Semmelweis University, Budapest, Hungary, 4 Department of Paediatric and Adolescent
Dentistry, Dentistry Program, Medical School, University of Pécs, Pécs, Hungary, 5 Department of Pediatric
and Preventive Dentistry, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
* segatto.emil@gmail.com
Abstract
Background
How dental education influences students’ dental and dentofacial esthetic perception has
been studied for some time, given the importance of esthetics in dentistry. However, no
study before has studied this question in a large sample of students from all grades of dental
school. This study sought to fill that gap. The aim was to assess if students’ dentofacial
esthetic autoperception and heteroperception are associated with their actual stage of stud-
ies (grade) and if autoperception has any effect on heteroperception.
Methods
Between October 2018 and August 2019, a questionnaire was distributed to 919 dental stu-
dents of all 5 grades of dental school at all four dental schools in Hungary. The questionnaire
consisted of the following parts (see also the supplementary material): 1. Demographic data (3
items), Self-Esthetics I (11 multiple- choice items regarding the respondents’ perception of their
own dentofacial esthetics), Self-Esthetics II (6 Likert-type items regarding the respondents’ per-
ception of their own dentofacial esthetics), and Image rating (10 items, 5 images each, of which
the respondents have to choose the one they find the most attractive). Both the self-esthetics
and the photo rating items were aimed at the assessment of mini- and microesthetic features.
Results
The response rate was 93.7% (861 students). The self-perception of the respondents was
highly favorable, regardless of grade or gender. Grade and heteroperception were significantly
associated regarding maxillary midline shift (p < 0.01) and the relative visibility of the arches
behind the lips (p < 0.01). Detailed analysis showed a characteristic pattern of preference
changes across grades for both esthetic aspects. The third year of studies appeared to be a
dividing line in both cases, after which a real preference order was established. Association
between autoperception and heteroperception could not be verified for statistical reasons.
1 / 14
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11352218). The questionnaire and photo series are Conclusion

provided as supplementary material.
Our findings corroborate the results of most previous studies regarding the effect of dental
Funding: The author(s) received no specific
education on the dentofacial esthetic perception of students. We have shown that the effect
funding for this work.
can be demonstrated on the grade level, which we attribute to the specific curricular con-
Competing interests: The authors have declared
tents. We found no gender effect, which, in the light of the literature, suggests that the gen-
that no competing interests exist.
der effect in dentofacial esthetic perception is highly culture dependent. The results allow no
conclusion regarding the relation between autoperception and heteroperception.

Introduction
Most contemporary societies put heavy emphasis on esthetic personal appearance. It is well
documented that dentofacial esthetics has a profound influence on one’s social perception [1],
and on self-perception as well [2–4]. For some time now, esthetics has been a central issue in
dentistry, as patients put increasing emphasis on this aspect—sometimes prioritizing it over
functional considerations [5, 6]. This “esthetic turn” in patients’ expectations prompted dental
professionals to investigate what counts as esthetic in dentistry, both from the perspectives of
the patient and the dentist.
A specific question that has been investigated in several studies since the 1980s is whether
dental education (the process of becoming a professional) has a significant effect on one’s per-
ception of dental esthetics [7–12].
While the methodologies and sample sizes of earlier studies dealing with the esthetic per-
ception of dental students were mostly proper, no study has ever considered all grades of the
dental school comprehensively. Armalaite and colleagues studied only 4th- and 5th- year stu-
dents [12], the student sample of Tufekci and colleagues consisted of 1st- and 3rd- year stu-
dents, while other studies did not even differentiate between grades, they treated dental
students as a homogeneous group instead.
Another issue that has been brought up by the cited studies is that of gender. The literature
is quite divided as to whether gender is a factor in dentofacial esthetic perception in the context
of becoming a dental professional.
In the present questionnaire- based, cross-sectional study, we sought to give a description
of the dynamics of dental esthetic perception in the process of dental education, covering all
five grades of the dental school in all four dental schools in Hungary. We sought to examine in
this large student sample if there is association between the stage of studies (grade) and a)
one’s esthetic self- perception and b) one’s esthetic preferences regarding various mini- and
microesthetic features, and c) if satisfaction with one’s dentofacial esthetics influences dentofa-
cial esthetic preferences. We also sought to study if gender plays a significant role in any of
these. As null hypotheses, we hypothesized that a) neither grade nor gender would have a sig-
nificant association with the students’ self-perception and b) esthetic preferences and that c)
self-perception would not have an effect on esthetic preferences.

Methods
Participants and sampling
All five grades of all the four dental faculties of Hungary (associated with the universities in
Szeged, Debrecen, Pécs and Budapest) were involved in the study. After having obtained the
deans’ approval, printed questionnaires were distributed among the faculties. Each faculty
received questionnaires the total number of their Hungarian-speaking students in each grade

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PLOS ONE Dentofacial esthetics as perceived by dental students

at the time +10% (to cover lost, damaged, etc. copies). Altogether 1011 questionnaires were
distributed for 919 students. The final sample size was determined by the number of non-
responders (see below). The authors administered the questionnaires personally to ensure that
the instructions and explanations would be the same at all sites and in each grade. 30 minutes
were allocated for answering the questions (including the rating of the photos). The question-
naires were anonymous, and participation was voluntary. Sampling took place between Octo-
ber 2018 and August 2019. The study protocol and the applied instrument were approved by
the Regional Ethics Committee for Research in Human Medical Biology at the University of
Szeged (No. 178/2018-SZTE). Written informed consent was not required. The students were
free not to participate or quit at any time.

The instrument
Several instruments exist that are related to dentofacial esthetics in some way. Traditional indi-
ces, such as the Dental Esthetic Index (DAI) or the Index of Orthodontic Treatment Need
(IOTN) are valid and reliable, but they were developed for older adults [13], and the assess-
ment of subjective satisfaction is not among the primary aims of these instruments [4]. For
these reasons, we could not use them for our study. Other indices, like Oral Health Related
Quality of Life (OHRQoL) do concentrate on subjective factors, but predominantly as deter-
mined by oral health in general [14], with esthetics only as a marginal factor. The Psychosocial
Impact of Dental Esthetics Questionnaire (PIDAQ) and the Orthognathic Quality of Life Ques-
tionnaire (OQLQ) may be the closest to what we needed for the present study, but still, we
found that some combination of the existing questionnaires would be the optimal.
It was for this reason that we developed our own instrument, by combining items from
already existing ones [2, 3, 15–17]. The instrument got the working name Dentofacial Esthetics
Instrument for Dental Students, was developed first in the Hungarian language (an authenti-
cated English translation exists but has not been tested), and it consists of the following parts
(see also the supplementary material): 1. Demographic data (3 items), Self-Esthetics I (11 mul-
tiple choice items regarding the respondents’ perception of their own dentofacial esthetics),
Self-Esthetics II (6 5-grade Likert-type items regarding the respondents’ perception of their
own dentofacial esthetics), and Image rating (10 items, 5 images each, of which the respon-
dents have to choose the one they find the most attractive). Both the self-esthetics and the
photo rating items were aimed at the assessment of mini- and microesthetic features, as
defined by Sarver [18]. Those features were chosen that are considered to influence the esthetic
perception of a smile the most [19, 20].
The smile photos for rating we prepared ourselves. The choice of the model was based on
the literature [10, 21, 22]: a clinically normal smile with normal occlusion and features that are
generally perceived as esthetic. The image was a standard frontal view showing the anterior
teeth, the surrounding gingival tissues and the lips. The image was cropped to remove the
chin, nose and cheeks to exclude the confounding effect of macroesthetic features. The photos
were taken from a 1.5 m distance, with a Nikon D7000 camera equipped with a Nikon 105mm
F 2.8G VR AF-S ED.IF Nikkor objective. The model was standing while being photographed.
The photo shooting session took place on a sunny day, in a room amply and evenly lit by natu-
ral light, at noontime.
For all esthetic features, the original (unmodified) photo and four modified versions of it
were used, so all series (as defined by one feature) consisted of 5 photos (Fig 1). Modifications
were always made to the unmodified image. For the modifications, Adobe Photoshop CC 2015
(Adobe Systems, USA) was used. The resulting 50 photos were arranged in an album in a way
that items from the same series were always shown on the same page, in random order. Life-

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PLOS ONE Dentofacial esthetics as perceived by dental students

Fig 1. A sample series of images from the album used for the study. The modified feature is the width of the buccal
corridor. A: the unmodified image. B-E: the buccal corridor widens by 1 mm steps up to + 4 mm (compared to the
unmodified image).
https://doi.org/10.1371/journal.pone.0230182.g001

size photos were shown. The respondents were not told which the unmodified variant was. All
image series with explanation are provided as supplementary material. The modifications are
summarized in Table 1. Please note that the questionnaire had not been formally evaluated
before this study.

Statistical analysis
Statistical analysis was carried out by an independent evaluator (see Acknowledgements). The
evaluator received the results in a coded format and was told what analyses to carry out accord-
ing to which codes. The evaluator was blinded to the meaning of the codes.
The results were analyzed in SPSS 22.0 (IBM, USA). Continuous variables were character-
ized by means with standard deviations and medians, categorical variables were described
with the number of observed cases and frequencies expressed in percentages. For hypothesis
testing, linear regression analysis, the chi-square test and the Kruskal-Wallis test were used, as
appropriate. For the analyses, the multiple-choice items were treated as categorical variables
and the Likert-type responses were treated as continuous variables (as they express degree
rather than discrete options). The level of significance was p = 0.05, unless otherwise indicated.

Results
Participants
Of the 919 students, 861 (93.7%) responded. Response willingness to the individual items was
also quite good, we managed to obtain 738 to 861 responses to each item. Items with missing

Table 1. Photo rating: The modified mini- and microesthetic features. See also supplementary material.
Series Item Feature Description
No. No.
1 4.1. Smile arc (SA) The relation of the maxillary incisal edges to the lower lip. From
markedly convex to markedly inverted. Arc modified by tilting
the maxillary arch in 10˚ steps upward and downward.
2 4.2 Gingival smile (GS) The degree of the visibility of the upper gingiva is modified by
shifting the arches downward.
3 4.3. Length of canines and lateral The length of the canines and lateral incisors is modified, in
incisors (LCLI) varying combinations.
4 4.4. Width of buccal corridor The width of the buccal corridor is increased, up to +4 mm as
(WBC) compared to the original.
5 4.5 Vertical position of the canine The position of the canine cusps is shifted above and below the
cusps (VPCC) arch level.
6 4.6 The zenith of the front teeth Horizontal, upward arching and downward arching variations.
(ZFT)
7 4.7 The length of frontal The length of the interdental papillae is modified a) between the
interdental papillae (LFIP) central and lateral incisors and b) between the lateral incisors
and canines.
8 4.8 Midline shift (MS) The midline, defined as the vertical line between the central
incisors, is shifted to right and left.
9 4.9 Position of the commissures The position of the commissures is shifted downward.
(PC)
10 4.10 The relative visibility of the The degree of the relative visibility of the arches is modified by
arches (RVA) moving them vertically behind the lips.
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PLOS ONE Dentofacial esthetics as perceived by dental students

Table 2. The number of students and distribution of genders by grade.

Grade N Gender (N(%))
1st 187 M: 71 (38%)
F: 116 (62%)
2nd 184 M: 61 (33%)
F: 123 (67%)
3rd 137 M: 41 (30%)
F: 96 (70%)
4th 169 M: 62 (37%)
F: 107 (63%)
5th 184 M: 66 (36%)
F: 118 (64%)
https://doi.org/10.1371/journal.pone.0230182.t002

responses were: 1.2 Age (N = 842); 2.8 Upper central midline (N = 763); 2.9 Lower central
midline (N = 742); 2.10 Upper and lower incisal midline alignment (N = 738); 2.11 Gummy
smile (N = 774). The mean age of the 861 respondents was 22.34 ± 4.2 years. The number of
students and distribution of genders in each grade are given Table 2.

Esthetic perception of own smile

As the chi-square test did not indicate a significant association between the responses to the
multiple choice items (2.1–2.11) and grade, and neither did we find a significant association
with gender (entered as a control variable), we concluded that grade and gender made no sig-
nificant difference on how esthetic students perceived their own smile according to the param-
eters we asked them about. Thus, to characterize students’ self-perception, we analyzed the
answers to these items as a whole, instead of breaking the analysis down to grades.
The percentages show that the students had a generally positive perception of their own
smile. 210 respondents (24.4%) indicated that they had tried to avoid smiling because of the
condition of their teeth at some point in their life or that it was a problem for them at the time
of sampling. 116 students (13.5%) indicated that they smile with closed mouth while being
photographed. 556 students (64.6%) said that they had never looked at somebody else wishing
that their smile would be like the smile of that person. 515 students (59.8%) responded with
“no” to the question as to whether they wished to change their smile in any way. The vast
majority of the respondents, 740 students (85.9%) were absolutely or partially satisfied with
the color of their teeth. Only 121 respondents (14.1%) indicated complete dissatisfaction. A
similarly high number of respondents, 688 students (79.9%) found that the shape and size of
their teeth were in harmony. Crowding of the teeth was a problem to 365 students (42.4%),
and 90 of them indicated that they had crowded teeth in both arches. 710 (82.5%) students
indicated that their interincisal line fell exactly in the midline of their face. 587 (68.2%) stu-
dents found that their lower interincisal line fell exactly in the midline of their face. 508 (59%)
students indicated that the upper and lower interincisal lines fell in the same line. It must be
noted in connection with the latter 3 items that >10% of all respondents indicated that they
had never observed these features of their smile. Finally, 586 (68.1%) students said no when
asked whether their upper gum was visible while smiling. 208 (24.2%) students said that their
gum was visible while smiling, and 67 (7.8%) students said that they had never observed/con-
sidered this.
As for the Likert-type self-evaluation (items 3.1–3.6), we used linear regression analysis to
determine if grade or gender had significant effect on the respondents’ choices. The effect of
grade and gender were analyzed in the same model. Similarly to the multiple choice items, no

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PLOS ONE Dentofacial esthetics as perceived by dental students

Table 3. Results of the Likert-type items. The respondents had to indicate how much they agreed with the given statements on a 1 to 5 scale where 1 meant not at all and
5 meant absolutely.
Item N Mean SD Median Mode Frequency of mode Min. Max.
3.1. How satisfied are you with the shape of your teeth? 861 4.34 0.76 4.00 5 48.32% 0.00 5.00
3.2. How satisfied are you with the size of your teeth? 861 4.43 0.83 5.00 5 56.80% 0.00 5.00
3.3. How satisfied are you with the orderliness of your teeth? 861 3.86 0.96 4.00 4 39.61% 0.00 5.00
3.4. How satisfied are you with the whiteness of your teeth? 861 3.66 0.94 4.00 4 43.32% 0.00 5.00
3.5. How satisfied are you with the harmony between your teeth and lips? 861 4.36 0.87 5.00 5 55.17% 0.00 5.00
3.6. How satisfied are you with the aesthetics of your smile in general? 861 4.07 0.87 4.00 4 45.53% 0.00 5.00
https://doi.org/10.1371/journal.pone.0230182.t003

significant effect was found for any of the items, and thus the sample was analyzed descrip-
tively and as a whole. The results are summarized in Table 3. The students were the most satis-
fied with the size of their teeth and the least satisfied with the whiteness (color) of their teeth.

Photo rating
The chi-square test indicated significant association between grade and items 4.8 (midline
shift, p < 0.01) and 4.10 (the relative visibility of the arches, p < 0.01). No significant associa-
tion was found with gender for any of the photo series. Figs 2 and 3 show the distribution of
preferences across the five grades.
As for the midline shift (Fig 2), it was a common finding for all grades that the 2 mm right
shift was the least preferred modification. Regarding the 2 mm left shift, an interesting pattern
was found: in the first grade, it was the second most preferred modification, almost exactly as
preferred as the most highly rated 1 mm left shift (with only 1% difference). In the second
grade, however, it ranked only fourth, but in the third grade, it became the most preferred vari-
ation. In the fourth grade, it fell back to the third place, and in the fifth grade it ranked third
too. To sum it up, there was a significant variation in the preference for this specific modifica-
tion across the grades. Another finding to mention is that the unmodified image was the most
preferred only in the fourth grade, in the rest of the grades, it ranked third. In the first, second
and fifth grades, the 1 mm left shift was the most preferred variation. In general, the prefer-
ences were quite evenly distributed across the variations, with not much difference between
the variations. The only exception seems to be the fifth grade, where the differences between
the preferences for each variation were the largest, resulting in what can be considered a real
rank order. Furthermore, the third year appears to be a turning point, where preferences

Fig 2. Distribution of preferences in the five grades for midline shift. The vertical line between the central incisors
was shifted to the left and to the right in 1 mm steps (percentages, N = 861).
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PLOS ONE Dentofacial esthetics as perceived by dental students

Fig 3. Distribution of preferences in the five grades for the relative visibility of the arches. The arches were moved
upward and downward behind the lips in 0.5 mm steps (percentages, N = 861).
https://doi.org/10.1371/journal.pone.0230182.g003

stabilize, and from the fourth year on, no real variation is seen in the preference order. Com-
paring the first and fifth grades, it is interesting to see that the preferences of the two grades are
almost the same, with the single exception of the 2 mm to left variation, which is almost as pre-
ferred as the first-ranking choice in the first year, but clearly falls back to the third place by the
fifth year.
As for the relative visibility of the arches (modified by moving the arches up and down
behind the lips, Fig 3), the variability of preferences across the grades is obvious at first sight.
The unmodified variation turned to be the most preferred in 3 of the 5 grades, but it never
ranked lower than 3rd (in the third grade). The least preferred variation, almost regardless of
grade, was the 1 mm downward shift (where the least of the lower arch is visible). Preferences
for the 1 mm up and 0.5 mm down variations varied the most across the grades. Similarly to
what was observed in connection with the midline shift, the third grade appears to be a turning
point, from where on, the preferences are distributed across the variations less evenly, and a
real rank order seems to develop. Unlike in the case of the midline shift, the preference order
in the fifth grade was markedly different from that in the first grade, except for the unmodified
variation being the most preferred one in both grades.
Regarding the rest of the photo series, we did not find significant association with grade,
that is, the sample showed approximately the same preferences, regardless of grade. In Table 4,
however, we provide the most and least preferred variations by grade, to give a characteriza-
tion of the preferences of the sample in general.

Table 4. The most and the least preferred variations by grade for the photo series where no significant association
with grade was found (N = 861). The conventions are the same as in Table 1.
Feature Most preferred (%) Least preferred (%)
SA Inverse 1 (55%) Concave 1 (0.6%)
GS Arches 2 mm up (44%) Arches 2 mm down (2.7%)
LCLI Canines 1 mm shorter (29%) Canines and lateral incisors 1 mm longer (11.5%)
WBC Unmodified (23.5%) Buccal corridor 2 mm wider (16%)
VPCC Cusps 1 mm above arch level (24.8%) Unmodified (15.8%)
ZFT Horizontal zenith (35.5%) Upward arching (8.73%)
LFIP Unmodified (31.2%) All papillae shorter (5.74%)
PC Unmodified (36%) Commissures 3 mm downward (12.35%)
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Self-perception and photo rating

Significant associations were found between items 3.1 and 4.10 for gender (p < 0.05), 3.2. and
4.10 for gender and grade (p < 0.01 and p< 0.01, respectively), and between 3.5 and 4.4 for
gender (p < 0.05). An in-depth crosstable analysis showed, however, that these were only
apparent effects stemming from the distorting effect of the extremely low number of students
with low self-evaluation scores. We concluded that the data did not support the existence of
significant association between dentofacial autoperception and heteroperception.

Discussion
The perception of dentofacial esthetics by dental students and dentists has been studied since
the 1980s. Brisman [7] compared patients, dental students and dentists regarding their esthetic
preferences in connection with maxillary central incisors. He found that the three groups sig-
nificantly differed in their preferences (indicating an effect of education), and that gender was
not a factor. Phillips et al. [8], studying orthodontics residents, dental students and non-dental
university students came to a similar conclusion regarding the effect of education. Tufekci
et al. [9] came to the same conclusion in their study of laypeople, orthodontic patients, and
first- and third-year dental students. Finally, Kokich et al. [10] demonstrated that being an
orthodontist does make one more critical about a number of dental esthetic features than gen-
eral dentists or laypersons. Interestingly enough, one study found no difference at all between
dentists and laypersons in this respect, but this can be probably put down to the unusually
small sample size of 10 respondents per group [11]. In summary, there seems to be a consensus
in the literature, regardless of geographical area, that studying dentistry does make a difference
in one’s perception of various dental esthetic features. There is less consensus as to whether the
gender of the student or dentist makes a difference. As mentioned before, Brisman [7], work-
ing in the New York area, found no gender effect. In contrast, Armalaite [12], studying a larger
sample of Lithuanian dental students, found a definite and significant difference between
males and females in the evaluation of a number of dental esthetic features from gingival smile
through dental crowding. They drew the conclusion that women were “more critical” regard-
ing these features. Finally, Alhammadi and colleagues [23] studied 408 Saudi Arabian dental
students, and came to the conclusion that “male dental students have a better perception of
facial and dental esthetics.” It is not clear if the remarkable difference between the results of
these studies is due to the different geographical locations, the difference between the studied
features or something else.
The general aim of the present study was to give a comprehensive, cross-sectional charac-
terization of a large sample of dental students from all grades of dental school in terms of their
dental esthetic (self-) perception, also considering gender as a factor. The reason for this was
that no study before has examined all grades together from the same cultural and geographical
region. We have shown that the effect of dental education can be demonstrated on the grade
level, however, no gender effect was found and no association between autoperception and
heteroperception could be reliably demonstrated. When interpreting our results, it must be
taken into consideration that the questionnaire was our own development and had not been
formally evaluated before the study, which is definitely a limitation.
Specifically, we sought to answer four research questions. First, we asked if there is associa-
tion between the stage of studies (grade) and dentofacial esthetic self- perception. We asked
this question because we assumed that dentofacial self-perception could influence dentofacial
preferences (hence the third research question). This we assessed with multiple-choice ques-
tions. Had we found such associations, we should have taken them into consideration when
analyzing the association between grade and esthetic preference. We found no such

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PLOS ONE Dentofacial esthetics as perceived by dental students

associations, though, and neither was the respondents’ gender significantly associated with
self-perception. It seems that the 861 respondents formed a more or less homogeneous, and
generally satisfied, group regarding dentofacial esthetic self-perception. While there were
lower-scoring items (like the whiteness of the teeth), none of the studied aspects scored an
average below 3 on a scale of 5. It is difficult to compare these results to any other published
result, as few studies before asked these questions specifically in connection with dental
students. The lack of gender effect was somewhat surprising, as literature (of non-dental) stu-
dents suggests that female students tend to be more critical about their body [24, 25]. It is to be
taken into consideration, though, that these studies mostly concentrated on body image as
related to body mass. Could it be that one’s dentofacial body image is an exception? Or is it
simply that dental students comprise a special group in this respect? The 2016 study of Strajnic
and colleagues [26] failed to find gender difference in self-perception and satisfaction with
dental appearance in patients (i.e. laypersons), which supports the former hypothesis. How-
ever, this question has been rarely discussed in the literature and definitely needs further
investigation.
The second question was if there is association between grade and esthetic preferences
regarding various mini- and microesthetic features. To assess this, we used digitally manipu-
lated images. Significant association was found between grade and a) midline shift and b) the
relative visibility of the arches, indicating that the preferences regarding these features showed
the highest variability across the grades. Gender did not turn out to be a significant factor in
this analysis either, so the results were analyzed by grade alone.
The importance of the maxillary midline in dentofacial esthetics is well documented. John-
ston and colleagues [27] studied the esthetic judgements of orthodontists and laypersons and
found that the greater the shift, the more unattractive the given smile is found. This was true
both for the professionals and the laypersons, regardless of gender, and reached significance if
the shift was >2 mm (in either direction). In the study of Armalaite et al. [12], shifted maxillary
midline was classified by both male and female (4th- and 5th- year) dental students as unaccept-
able. Alhammadi and co-workers report that the dental students in their study noticed as small
a shift as 1 mm [23]. It seems, thus, that the position of the maxillary midline is a sensitive
esthetic issue, so it came as no surprise that in our study it was one of the parameters signifi-
cantly associated with the stage of studies. It is an intriguing finding that in 3 of the 5 grades,
the 1 mm left- shifted variation was the most preferred, and even in the remaining two grades
(the 3rd and the 4th), it was the second most preferred, only a few per cents behind the most
preferred ones. The unmodified variation was the most preferred only in the 4th year. It is diffi-
cult to offer any rational explanation other than that the studied population does actually pre-
fer a not precisely centered midline. While studies take zero deviation as the norm, it is safe to
assume that preferences in this respect vary across cultures and geographical areas. As for the
supposed effect of dental education, Fig 2 clearly shows the difference of preference orders
between the grades and that a real rank order with actually meaningful differences is estab-
lished only by the end of the studies.
The other modified feature to show significant association with grade was the relative visi-
bility of the upper and lower arches. While there was a clear tendency in all grades toward pre-
ferring the unmodified variation (it was the most preferred one in three of the five grades), the
1 mm up and 0.5 mm down variations obviously divided the students. For instance, the 1 mm
up variation (ranked generally low) was the most preferred in the 3rd grade, but the least pre-
ferred in the 4th. What the reason is for this high variability regarding these variations is not
clear. The general unpopularity of the 1 mm up variation would be easily explained by the fact
that it could remind respondents of edge-to-edge bite, taught as a form of malocclusion from
the earliest stages of dental studies. However, it does not explain the high popularity seen in

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PLOS ONE Dentofacial esthetics as perceived by dental students

the 3rd grade. If this is a unique result and not an artifact, it probably reflects the fact that stu-
dents in the Hungarian dental curricula begin to deal with the finer details of dental esthetics
after the 3rd grade (in the clinical module of the curriculum). This would explain why prefer-
ence ratios do not reflect a clear rank order before the 4th and 5th grades. While modification
of the midline is a relatively crude modification, the relative visibility of the arches is a finer
issue. It is possible that the 0.5 mm steps of modification were too fine for the students to allow
a clear-cut order of preference before being able to think consciously about it. However, in
lack of published data on this parameter, it is difficult to offer a firm explanation.
Why exactly the perception of these two features showed association with grade might have
several reasons, from cultural factors through the exact contents of education regarding dental
esthetics. However, the discussion of such background factors is clearly beyond the scope of
this paper, especially that we did not gather related data. The results, however, confirm the
finding of other studies that there is an association between dental knowledge (expressed as
grade in this study) and the esthetic perception of dentofacial features.
As for the items not significantly associated with grade, the following pattern was found:
the unmodified variation was the most preferred one in only 3 items of the 8 (the width of the
buccal corridor, the length of the frontal interdental papillae and the position of the commis-
sures), and in one item (the vertical position of the canine cusps) it was the least preferred one.
The latter finding was not entirely unexpected: our photo model had long canines, which
means that in the unmodified variation of the photo, the canines extended below the incisal
edges of the central incisors. Li and colleagues, working with similar frontal photos to ours,
found that both orthodontic experts and laypersons showed low tolerance regarding the differ-
ence between the length of the central incisors and canines and preferred situations when the
canines where slightly shorter [28]. Our results corroborate this: shorter canines were pre-
ferred over longer ones. As for gingival smile, the choices indicated a marked preference for
the invisibility of the gingiva, the variation with the least visible gingiva being the most pre-
ferred one. At first sight, our results seem to agree with the literature. The student sample of
Armalaite et al. [12] rated gingival smile “esthetically unacceptable”, and there appears to be a
general agreement in the literature that gingival smile is a medical condition, as treatments are
proposed [29]. It must be added, though, that this extremely negative evaluation is not uniform
across cultures: studies from Brazil [30] and Japan [31] reported that the visibility of the gin-
giva does not necessarily influence the esthetic judgement of smile. Concerning the smile arc,
the slightly inverted arc was the most frequent choice, which, again, is a slight deviation from
what is generally considered to be the esthetic norm (i.e. a slightly convex arc that contours the
lower lip) [32]. These can be regarded as esthetic preferences that were generally characteristic
of the entire sample, regardless of grade and gender.
Finally, we asked if satisfaction with one’s dentofacial esthetics influences dentofacial
esthetic preferences. In this respect, we found significant associations between satisfaction
with the shape of one’s teeth and the relative visibility of the arches in the photo series; satisfac-
tion with the size of one’s teeth and the relative visibility of the arches in the photo series; and
satisfaction with the harmony between one’s teeth and lips and the width of the buccal corridor
in the photo series. The detailed crosstable analysis indicated that the observed significance in
these cases was statistical artifact, and thus we concluded that our data did not allow the con-
clusion that dentofacial autoperception influences dentofacial heteroperception. This does not
necessarily mean that such an effect does not exist, though. Even if our sample was large
enough to allow conclusions, our respondents were predominantly satisfied with their dento-
facial esthetics, which confounded the analysis. Further studies are definitely needed, especially
that, to our knowledge, this study has been the first to ask this question.

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PLOS ONE Dentofacial esthetics as perceived by dental students

Conclusions
To our knowledge, our study has been the first to study the dentofacial esthetic auto- and het-
eroperception of dental students at all grades of dental school, in a large and culturally homo-
geneous sample. Our findings corroborate the results of most previous studies regarding the
effect of dental education on the dentofacial esthetic perception of students. We have shown
that the effect can be demonstrated on the grade level, which we attribute to the specific curric-
ular contents. In this respect we suggest that the study of how specific curricular contents
influence the dentofacial esthetic perception of students is a promising direction for future
research. We found no gender effect, which, in the light of the literature, suggests that the gen-
der effect in dentofacial esthetic perception is highly culture dependent. Finally, we failed to
confirm association between autoperception and heteroperception, but as the analysis was
confounded by the uneven distribution of the data, we cannot conclude that no such associa-
tion exists.

Supporting information
S1 Data. Dentofacial aesthetics instrument for dental students.
(PDF)
S2 Data.
(PDF)

Acknowledgments
The authors would like to express their gratitude to Dr. Gábor Braunitzer of dicomLAB Dental
for his selfless help with data management and analysis.

Author Contributions
Conceptualization: Lı́via Romsics, Angyalka Segatto, Kristóf Boa, Ildikó Szántó, Judit Nemes,
Emil Segatto.
Data curation: Noémi Rózsa, Judit Nemes.
Investigation: Lı́via Romsics, Angyalka Segatto, Kristóf Boa, Roland Becsei, Noémi Rózsa,
Ildikó Szántó, Judit Nemes.
Methodology: Roland Becsei, Noémi Rózsa, Judit Nemes.
Project administration: Angyalka Segatto.
Supervision: Angyalka Segatto, Emil Segatto.
Writing – original draft: Lı́via Romsics, Angyalka Segatto, Roland Becsei, Emil Segatto.
Writing – review & editing: Kristóf Boa, Noémi Rózsa, Ildikó Szántó, Judit Nemes.

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